Child's full name: (required)
Child's Date of Birth: (required)
Parent/guardian names: (required)
Emergency Contact Phone
How did you hear about us?
Online searchOur websiteFacebookInstagramUniting CareFeros CareAdvertisement/PosterBrochure/FlyerClinic newsletterLecture/ WorkshopLinkedInHealth professional (add name below)Friend (add name below)Other (add below)
Health professional's name
If other, let us know below
Want to add more doctors or specialists?:
Second Doctor or Specialist details
Third Doctor or Specialist details
eg: OT, speech therapist, dietician, social worker, psychologist
Name & Role:
Want to add more therapists or therapy services?:
Second Therapist or Therapy Service details
Name & Role:
Third Therapist or Therapy Service details
Name & Role:
Name of Daycare or School:
What are your child’s strengths? What does he/she like to do?
What are your concerns for your child?
What are the 2 main things you would like to achieve by the end of your first appointment?
Diagnosed health/ medical/ developmental conditions:
Does your child have/ has your child had:
AllergiesAsthma Epilepsy/ seizuresBehavioural difficultiesVisual difficultiesHearing difficultiesCardiovascular conditionHormone conditionSkin conditionRespiratory condition/illnessGastrointestinal disorderEating or drinking difficultiesInjuryOther (add below)
Please provide details:
Medications - Please list and state reason for each:
Equipment/ supports/ orthotics – Please include what your child already has and/or might need:
Have you seen another therapist before? If so – what do you think has worked for your child? Is there anything that you were not happy with about your previous therapist/s? What were you most happy with?:
Your/ your child's personal and health information is collected, used and disclosed by Move and Play Paediatric Therapy for the following reasons:
Administrative purposes including follow up notices, reminders, and appointment confirmations.
Communication with others involved in your child’s healthcare outside of Move and Play Paediatric Therapy for the purposes of seeking additional information, second opinions, and/or referral to other health professionals or providers to ensure your child receives optimal care and outcomes.
Clinical discussions with other health care professionals and students working for Move and Play Paediatric Therapy for the purpose of optimising client care and teaching.
Billing purposes, including compliance with Medicare, Health Insurance, and other government health funding programs such as Better Start and the National Disability Insurance Scheme.
For quality assurance activities to improve individual and community health care and service management.
For the purposes of research only where de-identified information is used.
To comply with any legislative or regulatory requirements eg: notifiable diseases, child protection mandatory reporting, or in response to a subpoena.
If you have any concerns or wish to restrict access to your or your child’s information please discuss these with your child’s therapist. This practice adheres to National Privacy Principles (www.privacy.gov.au) and has a written policy available for your perusal.
Therapy treatment is generally an effective and safe form of treatment however like any treatment there are benefits and risks.
Therapists in this practice will discuss your child’s condition and options for treatment so that you are appropriately informed and can make decisions relating to treatment. You may choose to consent or refuse any form of treatment for any reason including religious or personal grounds. Once you have given consent, you may withdraw that consent at any time.
I consent for my child to receive Therapy services from Move and Play Paediatric Therapy (required)
I consent to the handling of my child’s information by Move and Play Paediatric Therapy for the purposes set out above, subject to any limitations on access or disclosure of which I notify Move and Play Paediatric Therapy. (required)
I consent to receiving Move and Play Paediatric Therapy information, newsletters & updates via email (required)
Your name (please print, required):
Relationship to child (required):
I confirm that the information provided in this form is true and correct. (required)
Thank you for your time taken to complete this form